When Filler becomes Fulminant: Recurrent Gluteal Necrosis After Unregulated Injection in an Immunocompromised Host

Authors:
Robert Giglio, Kristin Chancellor, Rohit Sharma

Body of Abstract:
Background:

Cosmetic buttock enhancement procedures, including injectable implant material, are increasingly performed outside regulated medical environments. These procedures can introduce high risk pathogens, resulting in deep soft tissue infections with significant morbidity, especially in immunocompromised patients. We present a case of recurrent, progressive gluteal and trochanteric infection secondary to prior unregulated filler injection requiring serial debridement, dermal matrix placement, and staged skin grafting.

Case Presentation:

A 59-year-old male with advanced HIV/AIDS (CD4 22), systemic sclerosis, prior pulmonary embolism, granulomatous ILD, COPD, asthma, and a long history of chronic draining wounds from non-medical grade buttock filler first entered our system in 2018. He underwent outpatient wound care followed by right-thigh excisional debridement in 2019 with subsequent split-thickness skin grafting, which healed appropriately.

In winter 2025, his left trochanteric wound acutely worsened with foul-smelling drainage. In May 2025, operative exploration revealed devitalized infected tissue down to fascia with extensive “cheese-like” granulomatous material extending over the gluteal musculature; the defect measured 17 × 8 cm. Cultures grew Enterococcus. After initial improvement, he developed new fluctuance, heavy drainage, and eschar formation. In July 2025 he was readmitted; debridement revealed pus-filled, grossly necrotic wounds now measuring 23 × 16 cm at the left glute and 10 × 7 cm over the sacrum. Cultures showed β-hemolytic Streptococcus and Pseudomonas aeruginosa, and he was treated with piperacillin–tazobactam and metronidazole.

Despite outpatient wound care and serial clinic debridements, progression continued. On 10/10/25 he underwent wide excisional debridement of skin, soft tissue, and fascia of the left thigh (44 × 17 cm), XCelliStem dermal matrix placement, and negative-pressure therapy. Additional operative debridements occurred on 10/15, 10/24, and 10/27 after cultures again grew Pseudomonas, prompting meropenem therapy. He underwent split-thickness skin grafting of the sacral wound with excellent take, followed by grafting of the lateral left leg on 11/24. He remains hospitalized undergoing wound-vac management with plans for transition to wet-to-dry dressings and outpatient follow-up.

Conclusion:

Non-regulated cosmetic filler injections can result in prolonged, recurrent, and anatomically extensive infections, especially in severely immunocompromised hosts. This case demonstrates the critical need for aggressive serial debridement, meticulous wound-bed preparation, culture-directed therapy, and staged reconstruction to achieve control of infection and successful closure